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Hemostatic Agents for the Management of Bleeding Risk Associated
The occurrence of bleeding following dental extraction is a relatively common complication. A history of therapy with oral anticoagulants represents a major favoring factor, both in patients treated with vitamin K-antagonists (especially warfarin) and with direct oral anticoagulants (DOACs). Several local hemostatic measures can be applied to limit the bleeding risk in these patients. The aim of this systematic review is to evaluate what measures can be adopted to limit the bleeding risk following dental extractions in patients treated with oral anticoagulants. A literature search was performed, and 116 articles were retrieved. Titles and abstract analyses excluded 91 articles, and three more articles were excluded following full-text analysis. The systematic review was performed on 22 articles. Among the included articles, 20 studies reported on patients treated with warfarin, and two studies on patients treated with DOACs. The agents employed included local intra-alveolar agents, tranexamic acid, and PRF. The included studies were all at moderate/high risk of bias. Moreover, limited evidence is available on hemostasis in patients treated with DOACs. The available evidence hinders stating the superiority of one agent over the others. Further research is advised to increase the level of evidence of the application of hemostatic agents in patients treated with oral anticoagulants.To get more news about hemorrhage control, you can visit rusuntacmed.com official website.
Dental extractions are the most common procedures performed in routine dental practice. Bleeding and oozing from the surgical wound are frequently encountered, and mostly self-limiting, complications [1]. However, in patients treated with vitamin K antagonists or direct oral anticoagulants (DOACs), additional measures may be required to manage and limit the risk of post-operative bleeding [1].
Vitamin K antagonists include coumarin and its derivatives such as warfarin. Their mechanism of action is based on the inhibition of prothrombin and clotting factors formation. Dose adjustments are often required in order to maintain the target International Normalized Ratio (INR) of 2.5 (therapeutic range 2–3) [2]. To date, warfarin is the most prescribed oral anticoagulant for the management of thromboembolic disorders, despite its narrow therapeutic index and the high variability in clinical response [3,4].
DOACs have been introduced in recent years for the management of several cardiovascular conditions, including treatment of venous thromboembolism, stroke prevention in non-valvular atrial fibrillation, and for thromboprophylaxis following orthopedic surgery [5]. The DOACs category includes four anticoagulants which directly inhibit the coagulation cascade. Dabigatran is a direct thrombin inhibitor, while apixaban, rivaroxaban, and edoxaban exert their pharmacological activity by inhibiting factor Xa [5]. DOACs are becoming increasingly used with respect to vitamin K antagonists due to their efficacy and safety [6]. It appears that a reduced risk of bleeding can be observed in patients treated with DOACs compared with warfarin as a therapeutic regimen, although in some cases monitoring is still advised [7].
Patients under oral anticoagulant therapy are more prone to bleeding complications and hematoma formation following dental procedures. Tooth extractions are the most frequently performed oral surgical procedures, and bleeding or oozing are frequently occurring complications [8,9]. The surgical trauma on both hard and soft tissues can be related to the development of post-extraction bleeding, although inflammation and/or infection of the extraction site can be concurrent factors [10]. In patients treated with oral anticoagulants, the bleeding risk is enhanced; therefore, different recommendations have been proposed, including anticoagulant therapy modulation through reduction, suspension, or bridging [11]. However, it has also been suggested that therapy discontinuation may expose the patient to a higher risk of thromboembolism against a modest risk of hemorrhage in patients with an INR within the therapeutic range [12].
At present, several hemostatic agents find application for the management of post-extractive bleeding in patients treated with oral anticoagulants. The aim of the present systematic review was to analyze the hemostatic agents employed to manage the bleeding risk associated with dental extraction procedures in patients undergoing oral anticoagulant therapy with vitamin K antagonists and DOACs.
Activated Prothrombin Complex Concentrate as a Hemostatic Agent in Hemophilia A
Activated prothrombin complex concentrate (aPCC) appears to be safe and highly effective as a hemostatic agent for acute bleeds due to acquired hemophilia A, according to a recently published study in the European Journal of Hematology. To get more news about hemostatic gauze, you can visit rusuntacmed.com official website.
Acquired hemophilia A is a rare autoimmune disease that mainly affects patients over the age of 60 years. It is associated with high mortality, reaching 38% in some studies. The high mortality is a consequence of sudden, spontaneous bleeds that can affect the gastrointestinal tract, urinary system, and nervous system.
Currently, bypassing agents such as aPCC represent the mainstay of treatment for acute bleeds in patients with acquired hemophilia A. However, there is scarce literature regarding the efficacy and safety of aPCC in a practical setting. The authors aimed to study the efficacy and safety of aPCC through a noninterventional retrospective study including 30 patients from several Spanish hospitals. All patients had a confirmed diagnosis of acquired hemophilia A, which was corroborated with a detectable anti-factor VIII inhibitor titer of at least 0.6 BU/mL and factor VIII (%) of less than 40%, and had received aPCC to treat a bleeding episode.
The parameters used to measure efficacy included bleeding cessation, pain control, and functional recovery of the affected system. Bleeding cessation was evaluated using clinician criteria in each case, and pain control was assessed through unidimensional pain scales.
Safety was measured by the presence or absence of adverse effects or death. There were 67 reported bleeds, the majority of which were spontaneous intramuscular bleeds. Gastrointestinal and genitourinary bleeds were also reported.
Approximately 50% of hemorrhages were treated with aPCC. It was used as initial therapy on 14 occasions and resolved the bleeding in 13 of them. In total, aPCC was used on 51 occasions, resolving the bleeding in 48.Use of aPCC was not associated with any thrombotic events. Three patients reported significant adverse effects after treatment, namely atrial flutter with decompensated heart failure, lower limb neuropathy, and hypofibrinogenemia. Four patients included in the study died within 30 days of finishing aPCC treatment from respiratory failure, sudden death, or fatal bleeds.
“Overall, our data add to previous knowledge indicating that aPCC is effective and [safe as a] hemostatic drug as first line or second line,” the authors concluded.
IFAK Pouch & Insert Kit
The Gen 2 TMK-IFAK Pouch and Insert Kit includes the necessary medical supplies to treat the three leading causes of preventable deaths on the battlefield: bleeding, tension pneumothorax, and airway obstruction.To get more news about hemorrhage control, you can visit rusuntacmed.com official website.
The TMK-IFAK Pouch and Insert Kit merges the unique capabilities of the IFAK Pouch and IFAK Insert into one complete system providing quick and easy access to medical supplies. When needed, simply use the access tab to open the pouch, grab the large red handle to extract the Insert, and deploy the Insert in one fluid motion. You can also tether the Pouch and Insert together so that essential medical gear is always within reach and can never be lost.
Improvements to our Gen 2 Pouch and Insert include the addition of plastic side stiffeners in the Pouch, allowing for smoother, easier loading and one-handed deployment of the Insert. We also added our bi-directional PALS system to enable both vertical and horizontal attachment using the two included MALICE CLIPS?.
Gauze With Hemostatic Agent Kaolin Shown
A new study has found the use of gauze that includes the hemostatic agent kaolin to be 100% effective in stopping traumatic bleeding by second application in a model of simulated hemorrhagic shock. In the study, treatment with QuikClot Combat Gauze®, a specially engineered surgical gauze impregnated with kaolin, successfully stopped bleeding in extreme physiologic conditions normally associated with a significant risk of fatality. Results were published in July 2012 in the peer review Journal of Surgical Research.iTo get more news about Профессиональный FАК, you can visit rusuntacmed.com.ru official website.
In the animal model study, researchers at the Department of Surgery at Madigan Health Systems used an established and validated ischemia-reperfusion swine model to produce clinically significant metabolic acidosis and dilutional coagulopathy, which are primary conditions associated with hemorrhagic shock. Subjects experienced a 35% blood volume loss and maintained significant metabolic acidosis and dilutional coagulopathy for six hours and 50 minutes. They then incurred a femoral artery injury and bled for two minutes before randomized treatment with either Combat Gauze® or standard gauze. A single application of Combat Gauze® was able to stop bleeding in 89% of subjects. Following a second round of treatment, Combat Gauze® was able to successfully stop bleeding in 100% of subjects. Treatment with standard gauze in the same model showed a 100% failure rate after the first application, and resulted in only one case of successful hemostasis after a second application.
"Traumatic bleeding associated with hemorrhagic shock is often fatal, and is unfortunately a common occurrence in military combat, in trauma associated with accidents and in law enforcement related injuries. This study shows conclusively that treatment with QuikClot Combat Gauze® is able to stop traumatic bleeding even in extreme physiological conditions that can result in hemorrhagic shock and often death," said Giacomo Basadonna , M.D., chief medical officer, Z-Medica Corporation.
In severe bleeding, the occurrence of acidosis, hypothermia and coagulopathy each can interfere with the body's ability to clot blood and can individually result in death if not treated. Once the body is affected by all three conditions, also known as the lethal triad, the death rate exceeds 90%.ii
"We know that death from hemorrhagic shock can be best avoided when bleeding is stopped early, and this study shows that a kaolin-based hemostatic agent is highly effective even in subjects who experience severe physiologic conditions for more than six hours. Treatment with QuikClot Combat Gauze®, which is easy to both carry and store, can be life saving for all service members and other trauma victims who are at risk of hemorrhagic shock, especially those who are far from medical help," said Scott Garrett, vice president, military and tactical programs, Z-Medica Corporation.
QuikClot Combat Gauze®, developed by Z-Medica Corporation, is the only product carried by all branches of the U.S. Military to control traumatic bleeding. The product is impregnated with kaolin, an inert mineral that quickly promotes blood clotting. It is indicated for external control of traumatic bleeding and is able to conform to any wound.
"The fact that QuikClot Combat Gauze® is as easy to carry, store and apply as standard gauze means that we can bring this potentially life-saving advantage to thousands of people affected by bleeding in the military, law enforcement, emergency medicine and other areas with no changes in standard operating procedures," added Dr. Basadonna.